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The Current Role and the Future of Minimally Invasive

Temporomandibular Joint Surgery

Article  in  Oral and maxillofacial surgery clinics of North America · February 2015

DOI: 10.1016/j.coms.2014.09.006 · Source: PubMed

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1
2
T h e Cu r ren t R o l e an d t h e
3
4
F u t u re o f M i n i m a l l y
5
6
I n vasive Temporom and ibu lar
7
8
J o i n t Su r g e r y
9
10 González-García, MD, PhD, FEBOMFSa,b,*
Q2Q3 Raúl
11
12
13 KEYWORDS
14  Minimally invasive temporomandibular joint surgery  Temporomandibular joint arthroscopy 57
15  Temporomandibular joint arthrocentesis 58
16 59
17 60
18 Q5 KEY POINTS 61
19 62
20  Minimally invasive temporomandibular joint surgery (MITMJS) is a reliable method for the treatment 63
21 of most internal derangement (ID) of the temporomandibular joint (TMJ), with a relatively low 64
22 complication rate. 65
23  Arthrocentesis is recommended for the treatment of acute or SACL of the TMJ for disk displace- 66
24 ment without reduction of less than 3 months evolution, whereas arthroscopy is definitively 67
25 preferred for the treatment of chronic closed lock of the TMJ (>3 months evolution). 68
26  Arthroscopy is indicated for ID of the TMJ, mainly Wilkes stages II, III, and IV, degenerative joint dis- 69
27 ease, synovitis, painful hypermobility, or recidivist luxation of discal cause, and hypomobility 70
28 caused by intra-articular adherences. 71
29  With an overall complication rate less than 1.5%, MITMJS seems to be safe, although the surgeon 72
30 must be aware of any potential complications during or immediately after the procedure. 73
31  In the future, MITMJS may evolve to the combination of arthroscopic and endoscopic techniques 74
32 with navigation for the treatment of TMJ disease, including ID, TMJ ankylosis, condylar hyperplasia, 75
33 and TMJ tumors. 76
34 77
35 78
36 79
37 80
38 INTRODUCTION with ankylosis, tumors, and growth abnormalities 81
Q6
39 of the TMJ may often need open surgical 82
40 1
As previously reported, some temporomandib- approaches. 83
41 ular joint (TMJ) diagnoses such as ankylosis, tu- It might be thought that this situation limits 84
42 mors, and growth abnormalities have an absolute MITMJS to secondary or minor indications. How- 85
43 indication for TMJ open surgery, whereas most ever, because most disorders related to TMD 86
44 disorders related to temporomandibular disease with primary involvement of the joint are TMJ in- 87
45 (TMD) have a relative indication for surgery, ternal derangement (ID) and osteoarthrosis, 88
46 because conservative nonsurgical management MITMJS becomes a definitive tool for alleviating
47 is often the first approach. Indications for mini- symptoms in terms of pain and function with
oralmaxsurgery.theclinics.com

48 mally invasive TMJ surgery (MITMJS) seem to be minimal expected morbidity. Moreover, MITMJS
49 restricted to this second group of patients with should be considered early in the management
50 relative indications for surgery, because patients sequence in some cases, even before the failure
51
52
53 a
Department of Oral and Maxillofacial-Head and Neck Surgery, University Hospital Infanta Cristina, Badajoz,
54
Q4 Spain; b University of Extremadura (UEx) School of Medicine, Badajoz, Spain
55
* Calle Los Yébene 35, 8 C, Madrid 28047, Spain.
56 E-mail address: raulmaxilo@gmail.com

Oral Maxillofacial Surg Clin N Am - (2014) -–-

http://dx.doi.org/10.1016/j.coms.2014.09.006
1042-3699/14/$ – see front matter Ó 2014 Published by Elsevier Inc.
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 2 González-Garcı́a

89 of conservative treatment, to avoid progression INDICATIONS OF MINIMALLY INVASIVE 146

90 of the disease to a more symptomatic stage or TEMPOROMANDIBULAR JOINT SURGERY 147
91 to a surgically nonrespondent phase of the Arthrocentesis 148
92 disease. 149
 Most of the studies in relation to the use of
93 This article focuses on the current role of 150
arthrocentesis for the treatment of ID of the
94 MITMJS in terms of indications, surgical tech- 151
TMJ have investigated its usefulness in
95 niques, clinical outcomes, and complications. 152
ACL. It is also an excellent diagnostic tool
96 Also, the future applications and possible evolu- 153
for the patient with unclear cause who pre-
97 tion of these techniques for the treatment of TMD 154
sents with functional limitations and pain of
98 are discussed. 155
the TMJ. Several indications have been
99 156
proposed17:
100 HISTORICAL SUMMARY 157
1. ACL of the TMJ: anterior displacement of
101 158
the disk without reduction of less than a
102 In 1975, Onishi2 first reported the use of the 159
month of evolution that does not respond
103 arthroscope in the TMJ for diagnostic purposes. 160
to passive manipulation of the mandible
104 In 1982, Murakami and Hoshino3 developed the 161
or conservative treatment
105 nomenclature of TMJ arthroscopic anatomy. In 162
2. Subacute closed lock (SACL): anterior
106 1983, McCain,4 in a cadaver study with 67 joints, 163
displacement of the disk without reduction
107 favored the development of routine TMJ arthros- 164
of 1 to 3 months of evolution that does not
108 copy. Holmlund and Hellsing,5 in a study of 54 165
respond to conservative treatment
109 cadavers, described anatomic key points to 166
3. Anchored disk phenomenon diagnosed by
110 make this technique secure and standardized. 167
nuclear magnetic resonance (NMR)
111 Several studies concerning the benefit of arthros- 168
4. TMJ trauma with chronic pain and capsuli-
112 copy for treating TMJ disease begin to appear in 169
tis caused by whiplash
113 the literature. In 1986, Sanders6 described the 170
5. Some cases of painful degenerative joint
114 benefit of arthroscopy for the treatment of acute 171
disease (osteoarthrosis) refractory to con-
115 closed lock (ACL) or chronic closed lock (CCL) 172
servative treatment
116 of the TMJ and introduced the term lysis as a 173
6. Inflammatory arthropathies: rheumatoid
117 distension of the joint with a blunt trocar to elim- 174
arthritis, juvenile idiopathic arthritis, sclero-
118 inate the suction effect of the disk to the fossa, 175
dermia; metabolic arthropathies: hyperuri-
119 and so lysing or breaking the adherences. In the 176
cemia, chondrocalcinosis, with important
120 same year, Murakami and Ono7 described the 177
articular pain as a temporary way of treat-
121 arthroscopic removal of intra-articular adher- 178
ing the patient’s symptoms
122 ences. In 1989, Israel,8 Tarro,9 and Ohnishi10 179
7. Patients who reject arthroscopy or who
123 independently first described the use of arthro- 180
cannot be submitted for general anesthesia
124 scopic suture for the treatment of anterior disk 181
 Some contraindications for arthrocentesis
125 displacement or recurrent mandibular disloca- 182
have also been proposed:
126 tion. Posteriorly, several techniques for arthro- 183
1. Psychiatric pathology
127 scopic suture were described by McCain and 184
2. Fibrous and osseous ankylosis
128 colleagues11 in 1992, Tarro12 in 1994, and 185
3. Multiply operated joints
129 Goizueta-Adame and Muñoz-Guerra13 and Yang 186
4. Regional infectious disease
130 and colleagues14 in 2012. Description of each of 187
5. Regional tumoral disease
131 these techniques and discussion of their advan- 188
132 tages and disadvantages are beyond the scope 189
Arthroscopy
133 of this article. 190
134 Because arthroscopic lysis and lavage (ALL)  The American Association of Oral and Maxil- 191
135 was already a reliable technique for treating lofacial Surgeons (AAOMS) established 5 192
136 TMJ ID, Murakami and colleagues,15 in 1987, main indications for arthroscopy of the 193
137 introduced arthrocentesis of the TMJ, by report- TMJ17: 194
138 ing the recapture of the anteriorly displaced disk 1. ID of the TMJ, mainly Wilkes stages II, III, 195
139 by mandibular manipulation after pumping and and IV 196
140 hydraulic pressure to the upper joint of the 2. Degenerative joint disease (osteoarthritis) 197
141 TMJ. In 1991, Nitzan and colleagues16 intro- 3. Synovitis 198
142 duced a modified method, which was based on 4. Painful hypermobility or recidivist luxation 199
143 the insertion of 2 needles in the upper joint of discal cause 200
144 space for lavage without direct visualization of 5. Hypomobility caused by intra-articular 201
145 the joint. adherences 202

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 Q1 Minimally Invasive Temporomandibular Joint Surgery 3

203  Some other indications have been proposed: accomplished only with operative or advanced 260
204 1. Inflammatory arthropathies (systemic arthroscopic techniques. However, some investi- 261
205 arthritis) gators18 have also reported the benefit of arthro- 262
206 2. Articular symptoms subsidiary to orthog- centesis for the treatment of CCL. I believe that if 263
207 nathic surgery arthroscopy can be performed, then CCL of the 264
208 3. Revision of the TMJ in cases of intra- TMJ is the main scenario for its application. Never- 265
209 articular implants theless, the results from our group suggest that 266
210  The main contraindications for TMJ arthro- arthroscopy is a useful technique for the treatment 267
211 scopic procedures are: of patients with CCL of the TMJ with minimal com- 268
212 1. Cutaneous, otic, or articular infection plications, showing a significant decrease in pain 269
213 2. Tumor with risk of extension with a parallel increase in mouth opening from 270
214 3. Severe fibrous or osseous ankylosis the first month postoperatively; these results 271
215 were predictable and stable for a minimum period 272
216 TMD specifically related to ID of the TMJ closed of 2 years.19–22 273
Q7
217 lock (ie, disk displacement without reduction) has 274
218 been reported to be effectively treated by CLASSIFICATIONS OF 275
219 MITMJS. According to our research, ACL or TEMPOROMANDIBULAR JOINT INTERNAL 276
220 SACL of the TMJ (<3 months of evolution) seems DERANGEMENT 277
221 to adequately respond to arthrocentesis as well 278
222 as to arthroscopy, whereas CCL (>3 months of The most popular classification for ID of the TMJ 279
223 evolution) may need arthroscopy for better control is that proposed by Wilkes (Table 1).23 Bronstein 280
224 and resolution of the disease. Because arthrocent- and Merrill24 added arthroscopic findings to the 281
225 esis may be less invasive than arthroscopy (partic- clinical and radiologic findings of previous 282
226 ularly, operative arthroscopy [OA]), it is ideal for the studies (Table 2). Other classifications such as 283
227 treatment of cases of recently established closed that by Molinari and colleagues25 have tried to 284
228 lock. Most of the long-standing cases may benefit simplify the precedents by evaluating disk 285
229 from the use of instrumentation over the displaced displacement in the anterior direction, because 286
230 disk and surrounding affected soft tissues, such as it is the most frequently observed. These investi- 287
231 the retrodiscal tissue. This process can be gators categorize the classification in 4 clinical 288
232 289
233 290
234 Table 1 291
Clinical and radiologic findings according to Wilkes classification for TMJ ID
235 292
236 Stage Clinical Findings Radiologic Findings
293
237 294
238 I No significant mechanical symptoms, no pain Slight forward displacement and good 295
239 or limitation of motion anatomic contour of disk 296
240 II First few episodes of pain, occasional joint Slight forward displacement and beginning 297
241 tenderness and related temporal anatomic deformity of disk, slight 298
242 headaches, increase in intensity of clicking, thickening of posterior edge of disk 299
joint sounds later in opening movement,
243 300
beginning transient subluxations or joint
244 locking 301
245 302
III Multiple episodes of pain, joint tenderness, Anterior displacement with significant
246 temporal headaches, locking, closed locks, anatomic deformity/prolapse of disk,
303
247 restriction of motion, difficulty (pain) with moderate to marked thickening of 304
248 function posterior edge of disk, no hard tissue 305
249 changes 306
250 IV Characterized by chronicity with variable and Increase in severity over intermediate stage, 307
251 episodic pain, headaches, variable early to moderate degenerative remodeling 308
252 restriction of motion, and undulating hard tissue changes 309
253 course 310
254 V Crepitus on examination, scraping, grating, Gross anatomic deformity of disk and hard 311
255 grinding symptoms, variable and episodic tissue, essentially degenerative arthritic 312
256 pain, chronic restriction of motion, changes, osteophytic deformity, subcortical 313
257 difficulty with function cystic formation 314
258 From Wilkes CH. Internal derangements of the temporomandibular joint: pathological variations. Arch Otolaryngol Head 315
259 Neck Surg 1989;115:469–77; with permission. 316

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 4 González-Garcı́a

317 374
Table 2
318 Classification of Bronstein and Merrill of TMJ ID in relation to Wilkes classification 375
319 376
320 Roofing 377
321 Stage (%) Arthroscopic Findings 378
322 379
I 80–100 Elongation of bilaminar zone, normal synovia and disk, no cartilage involvement
323 380
II 50–100 Elongation of bilaminar zone, synovitis with adherences in initial phase,
324 381
anterolateral prolapse of the capsule
325 382
326 III 25–50 Elongation of bilaminar zone, important synovitis, decrease of lateral recess, 383
decrease of lateral recess, adherences, chondromalacia I–II
327 384
328 IV 0–25 Hyalinization of posterior ligament, synovitis, adherences, chondromalacia III–IV 385
329 V 0 Retrodiscal hyalinization, disk perforation, fibrillation of articular surfaces, 386
330 advanced synovitis, gross adhesions, chondromalacia IV 387
331 From Bronstein SL, Merrill R. Clinical staging for TMJ internal derangement: application to arthroscopy. J Craniomandib 388
332 Disord 1992;6:7–16; with permission. 389
333 390
334 391
stages, based on the degree of disk displace- 1. Medial synovial drape with distinct supe-
335 392
ment, the reversibility of disk displacement dur- rior to inferior striae
336 393
ing opening and closing movements, and 2. Oblique protuberance of the retrodiscal
337 394
changes in disk morphology observed by NMR. synovium
338 395
Despite this simplification, the classifications by 3. Posterior slope of the articular eminence
339 396
Wilkes23 and Bronstein and Merrill24 are most with distinct anterior to posterior striae
340 397
frequently used. 4. Anterior disk synovial crease: juncture of
341 398
anterior synovium and anterior band of
342 399
ARTHROSCOPIC ANATOMY OF THE disk
343 400
344 TEMPOROMANDIBULAR JOINT 401
The first area to be arthroscopically examined
345 The TMJ is a synovial joint between the temporal is the medial synovial drape (Fig. 2), which has 402
346 bone and the mandibular condyle, which presents a gray-white translucent lining and a tense 403
347 both superior and inferior spaces, with an inter- appearance with distinct superior to inferior 404
348 posed disk between them.17 The superior joint 405
Q8
349 space (SJS) is cranially limited by an articular sur- 406
350 face that covers the articular eminence and the 407
351 mandibular fossa.17 408
352 409
353  Within the SJS, 7 areas can be examined 410
354 (Fig. 1). These areas are: 411
355 1. Medial synovial drape 412
356 2. Pterygoid shadow 413
357 3. Retrodiscal synovium: 414
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358 a. Zone 1: oblique protuberance 415

359 b. Zone 2: retrodiscal synovial tissue 416
360 attached to posterior glenoid process 417
361 c. Zone 3: lateral recess of retrodiscal sy- 418
362 novial tissue 419
363 4. Posterior slope of articular eminence and 420
364 glenoid fossa 421
365 5. Articular disk Fig. 1. The TMJ and the arthroscopic areas to be ideally 422
366 6. Intermediate zone examined. 1, articular disk; 2, synovial lining in the 423
367 posterior recess; 3, glenoid fossa; 4, posterior slope of 424
7. Anterior recess:
the eminence; 5, articular eminence; 6, medial-anterior
368 a. Disk synovial crease 425
corner of the anterior recess; 7, lateral-anterior corner
369 b. Midportion of the anterior recess; 8, condyle. (From González-
426
370 c. Medial-anterior corner Garcı́a R, Gil-Dı́ez Usandizaga JL, Rodrı́guez-Campo FJ. 427
371 d. Lateral-anterior corner Arthroscopic anatomy and lysis and lavage of the 428
372  Four classic anatomic landmarks have been temporomandibular joint. Atlas Oral Maxillofac Surg 429
373 described: Clin North Am 2011;19:131–44; with permission.) Q13 430

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 Minimally Invasive Temporomandibular Joint Surgery 5

431 488
432 489
433 490
434 491
435 492
436 493
437 494

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438 495
439 496
440 497
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441 498
442 499
443 500
444 Fig. 4. Retrodiscal synovium and posterior ligament 501
445 of a right TMJ examined by arthroscopy. Note the 502
446 prominence of the posterior ligament through the sy- 503
447 novia when the disk is anteriorly pulled by the assis- 504
448 Fig. 2. Medial synovial drape of a right TMJ examined tant through passive mouth opening during the 505
by arthroscopy. Note the oblique protuberance down arthroscopic procedure. Focal areas of hyperemia are
449 506
and focal areas of hyperemia in the medial synovial observed. Note the milky white and highly reflective
450 disk at the right side of the image. 507
drape. The posterior band of the disk is visualized at
451 the right side. The temporal fossa is partially appreci-
508
452 ated in the upper side of the image. 509
453 joint is the posterior slope of the articular 510
454 eminence (Fig. 5). The fibrocartilage is white 511
455 striae. The second area to be examined is the and highly reflective and is thick in the back slope 512
456 pterygoid shadow (Fig. 3), with a purple appear- of the eminence. The articular disk, which is the 513
457 ance, which is located anterior to the medial sy- fifth area to be examined (Fig. 6), is milky white, 514
458 novial drape. The third area to be examined is highly reflective, and without striae. Normally, 515
459 the retrodiscal synovium (Fig. 4). Here, the syno- the disk glides fluently along the articular 516
460 vial membrane covers the posterior insertion of eminence. The concept of roofing evaluates the 517
461 the disk and is reflected superiorly to the tempo- covering of the articular disk over the condyle. 518
462 ral fossa. While the mouth is open, the posterior Roofing is graded arthroscopically according to 519
463 insertion covered by the synovial lining appears the posterior band of the articular disk and its po- 520
464 as a crest or crease. This finding is named obli- sition relative to the articular eminence. When it is 521
465 que protuberance. The fourth area of the superior measured with the condyle forward, the disk is in 522
466 normal position (roofing 100%) if the posterior 523
467 band of the disk is lying adjacent to the posterior 524
468 525
469 526
470 527
471 528
472 529
473 530
474 531
475 532
476 533
477 534
478 535
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479 536
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480 537
481 538
482 539
483 540
484 541
485 Fig. 5. Posterior slope of the articular eminence of a 542
486 Fig. 3. Pterigoid shadow of a right TMJ examined by right TMJ examined by arthroscopy. Note the 543
487 arthroscopy. Focal areas of hyperemia are visualized. healthy-appearing area of the examined surfaces. 544

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 6 González-Garcı́a

545 602
546 603
547 604
548 605
549 606
550 607
551 608
552 609
553 610
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554 611
555 612
556 613

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557 614
558 615
559 616
560 Fig. 6. Articular disk, which in normal conditions is 617
561 milky white, highly reflective, and without striae, as 618
562 seen in Figs. 2–5 and 7. Here, a perforation of the disk 619
563 was observed during the arthroscopy. Note that the 620
condylar pole is visualized through the upper joint Fig. 8. Anterior recess of a right TMJ examined by
564 arthroscopy. This is the typical area for triangulation 621
compartment (right), while the margins of the remnant
565 disk are palpated and gently pushed back by a blunt and introduction of a working cannula whenever 622
566 probe through the working cannula (left). possible. Miotomy of the lateral pterigoid muscle 623
567 and anterior release may be performed in cases of 624
568 closed lock with anterior disk displacement. 625
569 slope of the articular eminence. With the condyle 626
570 seated, it is 100% roofed if the posterior band of 627
the anterior disk synovial crease can be
571 the disk abuts at approximately the midportion of 628
observed, and this is the ideal place for insertion
572 the glenoid fossa. The intermediate zone is the 629
of the second or working cannula.
573 sixth area to be examined (Fig. 7). Without disor- 630
574 ders, this area has a white on white appearance, 631
SURGICAL TECHNIQUES
575 and the concavity of the disk can be observed. 632
Arthrocentesis
576 The anterior recess (Fig. 8) is the seventh area 633
577 to be examined. It begins with the condyle This procedure is usually performed under local 634
578 seated. In this area, the anterior disk synovial anesthesia with or without intravenous sedation. 635
579 crease, which is the fourth classic anatomic land- Once the preauricular area is disinfected, the 636
580 mark, is identified. At the anterolateral site, the posterolateral puncture site is performed 10 mm 637
581 union between the lateral synovial capsule and ahead of and 2 mm below the canthal-tragal 638
582 line. At this point, local anesthesia is used to infil- 639
583 trate the joint by perforating the capsule with an 640
584 intramuscular needle. Up to 2 cm3 of bupivacaine 641
585 0.5% or lidocaine 2% with adrenalin 1:100,000 642
586 are infiltrated into the joint. With the patient’s 643
587 mouth gently opened, the syringe must be 644
588 directed in a 45 angle from posterior to anterior 645
589 and from downward to upward until the edge of 646
590 the temporalis fossa at approximately 15 mm 647
591 from the skin is palpated. Posteriorly, the syringe 648
592 is directed anteriorly to the eminence until the in- 649
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593 jected fluid leaks out of the joint into the syringe. 650
594 A more anterior puncture with an intramuscular 651
595 needle at 20 mm ahead of and 7 mm below the 652
596 canthal-tragal line is used for drainage. Instilla- 653
597 tion of up to 250 to 300 cm3 of Ringer solution 654
598 is recommended for the entire procedure. After 655
599 Fig. 7. Intermediate zone of a right TMJ examined by lavage of the upper compartment, substances 656
600 arthroscopy. Note the disk (bottom) and the eminence such as corticoids or sodium hyaluronate can 657
601 (top). be instilled (Fig. 9). 658

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 Minimally Invasive Temporomandibular Joint Surgery 7

659 is performed. This maneuver allows distension of 716

660 the joint and facilitates the insertion of the cannula 717
661 into the joint. According to the description by 718
662 McCain and de la Rua,26 the first cannula has to 719
663 be placed at the maximum concavity of the gle- 720
664 noid fossa, by direct palpation. After the introduc- 721
665 tion of the sharp trocar through the skin, the ledge 722
666 723
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of the zygomatic bone at the fossa level must be

667 palpated. Once it has been stepped off, the trocar 724
668 is directed in a superior and slightly anterior 725
669 fashion until a resistance is noted. With a 726
670 controlled pressure and rotational movements in 727
671 a deeper vector, the capsule of the joint is 728
672 penetrated. 729
673 Fig. 9. Arthrocentesis of the TMJ. Continuous irriga- At this point, the sharp trocar is removed and a 730
674 tion with Ringer solution through a double- blunt trocar is used for further introduction of the 731
675 puncture technique. cannula. In our experience, most of the patients 732
676 need the cannula to be introduced up to 25 to 733
677 30 mm from the skin surface, although with 734
Arthroscopic Lysis and Lavage
678 some very thin patients, it needs to be introduced 735
679 ALL can be performed by a single-puncture or a only up to 20 mm. Immediately, the arthroscope 736
680 double-puncture technique. If a single-puncture is introduced through the cannula to check if it 737
681 technique is used, lysis is directly performed with is effectively placed into the joint space. The 738
682 the arthroscope. When a double-puncture tech- structures of the superior joint compartment at 739
683 nique is used, the second cannula is used for the the posterior recess have to be clearly visualized 740
684 introduction of the instruments that break the in the monitor. If not, the cannula may not be 741
685 adherences, such as hooked probes or biopsy for- adequately placed into the joint space, and the 742
686 ceps, under direct vision.25 In contrast to ALL with introduction of the cannula has to be repeated. 743
687 a double-puncture technique, OA (or advanced Once the cannula is adequately placed inside 744
688 arthroscopy) uses 2 or more working cannulas the superior joint, a 22-gauge needle is inserted 745
689 for the introduction of instrumentation to perform 5 mm anterior and 5 mm inferior to the fossa 746
690 procedures other than lysis of adherences, such puncture site until a continuous irrigation with 747
691 as debridement, miotomy of the pterigoid muscle Ringer lactate solution is obtained. Sweeping is 748
692 for anterior release of the disk, disk reduction, ret- performed with direct visualization for lysis of 749
693 rodiscal scarification, and suture or rigid disk possible adherences. Lavage with approximately 750
694 fixation. 250 to 300 mL of Ringer solution is performed 751
695 Previously to the insertion of the cannula, an (Fig. 10). Although the introduction of a second 752
696 intramuscular G21 green 0.8  24 mm needle is cannula is not necessarily accompanied by the 753
697 introduced in the joint at the same point as the performance of any technique over the tissues 754
698 cannula at the most concave point of the glenoid of the joint other than lysis of the adherences 755
699 fossa, and insufflation with 2 to 3 mL Ringer lactate with instrumentation, it is clearly indicated for 756
700 757
701 758
702 759
703 760
704 761
705 762
706 763
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707 764
708 765
709 766
710 767
711 768
712 769
713 Fig. 10. ALL. (A) Introduction of the scope posteriorly and insertion of the 22-gauge needle as a drainage ante- 770
714 riorly to the scope. (B) Establishment of a continuous Ringer solution irrigation from the scope to the drainage 771
715 needle. 772

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 8 González-Garcı́a

773 OA or advanced arthroscopy, because instru- 830

774 mentation is not usually necessary to eliminate 831
775 most of the adherences of the joint. 832
776 833
777 834
778 Operative or Advanced Arthroscopy 835
779 The first part of the procedure is the same as that 836
780 for ALL. Whenever possible, the first cannula with 837
781 the scope must be directed to the anterior recess 838

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782 of the joint under direct visualization. This pro- 839
783 cess can be accomplished with the joint 840
784 completely seated in the fossa. The working can- 841
785 nula is introduced from an entrance point in the 842
786 skin at a distance similar to that from the skin to 843
787 the tip of the first cannula, following the same 844
788 vector, according to the principles of triangula- 845
789 tion, which serve to blindly bring 2 objects
Fig. 12. Use of the RFC instrumentation for treating 846
790 synovitis of the retrodiscal tissue in the posterior 847
together in space (Fig. 11).26 The sharp trocar/ recess of the upper joint compartment.
791 cannula penetrates perpendicular to the skin, 848
792 tracing a triangle with the first cannula, looking 849
793 for the tip of the scope. Once the sharp trocar is 850
794 removed and the blunt trocar introduced through In cases in which the superior compartment is 851
795 the working cannula, both the first and the work- collapsed because of fibrosis or advanced 852
796 ing cannula have to be moved in a synchronized arthrosis, the entrance point at the skin must be 853
797 manner so as not to lose the visualization of the placed at approximately 1 cm ahead of and 1 cm 854
798 working cannula. At the anterior recess, a miot- below the entrance point of the first cannula, 855
799 omy of the lateral pterigoid muscle can be per- following the principles of triangulation. Tools can 856
800 formed by the introduction of a radiofrequency be introduced through the working cannula, such 857
801 coblation (RFC) terminal through the working as forceps, scissors, hooks, electric blade, laser 858
802 cannula in cases in which disk displacement (CO2 laser or holmium yttrium aluminum garnet 859
803 without reduction is observed. Once this proce- laser) and RFC terminals. The use of instrumenta- 860
804 dure has been performed, both cannulas are tion for arthroscopic surgery of the TMJ has been 861
805 moved backwards to the posterior recess. RFC reviewed by McCain and Hossameldin.27 Also, 862
806 can be used for cauterization of areas of synovitis substances such as sodium hyaluronate, cortico- 863
807 at the retrodiscal tissue (Fig. 12). steroids, plate-derived growth factors, and 864
808 nonsteroidal antiinflammatory drugs can be infil- 865
809 trated in the lumen or subsynovially through the 866
810 working cannula with direct visual control of the 867
811 puncture site, in contrast to what is performed by 868
812 arthrocentesis or ALL with a single-puncture 869
813 technique. 870
814 Miotomy of the lateral pterigoid muscle is per- 871
815 formed in the context of arthroscopic discopexy, 872
816 followed by disk reduction, retrodiscal scarifica- 873
817 tion, and disk fixation. Most of the cases in which 874
818 discopexy is performed are patients with ID pre- 875
819 senting with disk displacement with or without 876
820 reduction. The aim of the procedure is to restore 877
821 the normal and functional anatomy of the joint. I 878
print & web 4C=FPO

822 use RFC for the anterior release of the disk by 879
823 miotomy of the lateral pterigoid muscle, and 880
824 also for the treatment of synovitis and scarifica- 881
825 tion or contraction of the retrodiscal tissue 882
826 (Fig. 13). RFC uses a controlled, non–heat- 883
827 driven process, in which bipolar radiofrequency 884
828 Fig. 11. Introduction of the working cannula by energy excites the electrodes in a saline solution 885
829 means of the triangulation technique. to generate charged plasma gas.26 The purpose 886

OMC699_proof ■ 20 October 2014 ■ 3:08 pm

 Minimally Invasive Temporomandibular Joint Surgery 9

887 of MITMJs are available in the literature; (2) inclu- 944

888 sion criteria for each technique are not usually 945
889 well defined; (3) there is no consensus among in- 946
890 vestigators on the way of measuring success. All 947
891 these issues make comparison among studies 948
892 difficult and subjected to bias. Improvement in 949
893 the severity of pain may be calculated as a relative 950
894 measure or percentage from the postoperative 951
print & web 4C=FPO

895 value in relation to the preoperative one. Another 952

896 way of measuring results is to establish a success 953
897 rate. When research is reported, it is desirable to 954
898 distinguish clearly which method of evaluation 955
899 was used, so that outcomes can be compared 956
900 among studies.28 957
901 958
902 Fig. 13. Use of the RFC instrumentation for anterior Arthrocentesis 959
903 release by miotomy of the lateral pterigoid muscle 960
in the anterior recess of the upper joint space. Several studies have shown promising results for
904 961
arthrocentesis, especially when used in cases of
905 962
acute disk displacement without disk reduction.
906 of scarification is to facilitate the posterior posi- 963
When compared with ALL, the latter generally
907 tioning of the disk after anterior release and 964
had a slightly superior overall success rate. In a re-
908 reduction. Disk fixation may be performed by 965
view of studies concerning the use of arthrocente-
909 introducing a second working cannula. Two 966
sis for the treatment of ID of the TMJ,29 with
910 main methods have been described: (1) suture 967
evaluation of 612 joints in 586 patients with ACL,
911 disk fixation and (2) rigid fixation. Detailed 968
a mean success rate up to 83.5% has been
912 description of each type of fixation is beyond 969
reported.
913 the scope of this article; the reader is referred 970
914 to McCain and Hossameldin27 and Yang and 971
Arthroscopic Lysis and Lavage
915 colleagues14 for future reading (Fig. 14). 972
916 Success rates for ALL in the literature according 973
917 to improvement of maximal interincisal opening 974
CLINICAL OUTCOMES
918 (MIO) and decrease of pain in the TMJ are pre- 975
919 Analysis of the literature concerning clinical sented in Table 3.4,30–44 The main concern 976
920 outcome of MITMJS for the treatment of ID iden- about the data provided in the literature is the 977
921 tifies 3 main concerns: (1) most of the studies are absence of homogeneity. Most of the investi- 978
922 retrospective series of cases, and only a few ran- gators refer to success rate in terms of the 979
923 domized studies comparing different techniques percentage of patients presenting with pain 980
924 reduction or increase of mouth opening. How- 981
925 ever, few investigators quantify the amount of 982
926 pain relief or the increase of mouth opening. To 983
927 alleviate this bias, it is recommended to measure 984
928 success of ALL and OA according to the criteria 985
929 of the AAOMS,45 later modified by Eriksson and 986
930 Westesson,46 who considered the technique 987
931 successful when (1) a visual analogue score 988
932 (VAS) score of less than 20 and (2) MIO of 989
933 35 mm or more were obtained. 990
934 Sanders and Buoncristiani,30 in a series of 137 991
print & web 4C=FPO

935 patients, observed an 82% success rate with pa- 992

936 tients presenting with MIO more than 40 mm and 993
937 scarce or complete absence of pain. Indresano31 994
938 reported a 73% global success rate for ALL in a 995
939 series of 50 patients with TMJ ID. Moses and 996
940 Poker,33 in a series of 237 patients (419 joints), re- 997
941 Fig. 14. Suture fixation of the disk with a 2/0 blue ported a 92% success rate for ALL in terms of 998
942 nylon for in a case of CCL with disk displacement decrease of pain and a 78% in terms of increase 999
943 without reduction. of MIO. Later series34,36–39,43 have reported an 1000

OMC699_proof ■ 20 October 2014 ■ 3:08 pm

 10 González-Garcı́a

1001 1058
Table 3
1002 Results in terms of success rate according to pain reduction and increase of mouth opening from most 1059
1003 relevant studies in patients with ID of the TMJ undergoing ALL 1060
1004 1061
1005 Patients with Pain Patients with Increase 1062
1006 Number of Global Reduction/Pain in MIO (%)/MIO 1063
1007 Patients Success Reduction in VAS/Pain Increase (mm)/MIO 1064
1008 Author, Year (Joints) Rate (%) Reduction (%) Increase (%) 1065
1009 Sanders & 137 82 —/—/— —/—/— 1066
1010 Q14 Buoncristiani,32 1987 1067
1011 Indresano,33 1989 50 (80) 73 —/—/— —/—/— 1068
1012 Moses et al,34 1989 92 (152) 92 —/—/— 80/—/— 1069
1013 1070
Moses & Poker,35 1989 237 (419) — 92/—/— 78/—/—
1014 1071
1015 White,36 1989 66 (100) 86 —/—/— —/—/— 1072
1016 Clark et al,37 1991 18 81 —/—/57 —/13/67 1073
1017 Moore et al,38 1993 63 87 —/—/— —/—/— 1074
1018 Mosby,39 1993 109 (150) 93 —/—/— —/—/— 1075
1019 Holmlund et al,40 1994 42 (42) 50 —/—/— —/—/— 1076
1020 Nitzan et al,18 1997 39 (40) 95 —/from 9.24 to 1.45 (in —/11/— 1077
1021 a 1–15 scale)/84 1078
1022 Kurita et al,41 1998 14 (16) 86 —/—/— —/—/— 1079
1023 1080
Sorel & Piecuch,42 2000 22 (44) 91 81/—/— 100/8/—
1024 1081
1025 Dimitroulis,43 2002 56 84 66/—/— —/9.8/— 1082
1026 Kondoh et al,44 2003 20 80 —/—/— —/10/— 1083
1027 Smolka et al,45 2008 39 (45) 87 89/—/— 74/—/— 1084
1028 González-Garcı́a & 156 — 75 (WII), 71 (WIII), 71 61 (WII), 73 (WIII), 52 1085
1029 Rodrı́guez-Campo,46 (WIV)a (WIV)a 1086
1030 2011 88 (WII), 86 (WIII), 87 74 (WII), 78 (WIII), 66 1087
1031 (WIV)b (WIV)b 1088
1032 Abbreviations: WII, Wilkes II; WIII, Wilkes III; WIV, Wilkes IV. 1089
1033 a
Data at 6 months postoperatively. 1090
1034 b
Data at 24 months postoperatively. 1091
1035 Data from Refs.18,32–46 1092
1036 1093
1037 1094
1038 overall success rate for ALL ranging from 50% to TMJ ID, reported success rates of 75%, 71%, 1095
1039 93% of patients. However, all these series lack in- and 71% for pain reduction for Wilkes II, III, and 1096
1040 formation regarding the amount of pain relief or IV, respectively, at 6 months postoperatively; 1097
1041 the amount of increase in mouth opening. Clark these rates improved to 88%, 86%, and 87% at 1098
1042 and colleagues,35 in a small series of 18 patients, 24 months postoperatively. In relation to mouth 1099
1043 reported a reduction of pain of 57% and a parallel opening greater than 35 mm, success rates 1100
1044 increase in mouth opening of 67% (13 mm). Nit- changed from 70%, 68%, and 35% for Wilkes 1101
1045 zan and colleagues18 reported more optimistic II, III, and IV, respectively, at 3 months postoper- 1102
1046 results for ALL in terms of overall success, with atively, to 75%, 79%, and 61% for Wilkes II, III, 1103
1047 95% of patients, 84% pain relief, and a mean in- and IV, respectively, at 12 months postopera- 1104
1048 crease of 11 mm in mouth opening. More tively. These data show that it is important to 1105
1049 recently, Dimitroulis41 reported an 84% overall report data in terms of staging and time of evalu- 1106
1050 success rate for ALL, with 66% of the patients ation, because of the changing course of the dis- 1107
1051 presenting with decrease of pain and an increase ease and the variability of signs and symptoms 1108
1052 of mouth opening of almost 10 mm. For a better according to stage. 1109
1053 understanding of the influence of Wilkes stages The status of the articular surface or the synovial 1110
1054 and postoperative follow-up on success rate con- lining may not necessarily improve after ALL, even 1111
1055 cerning pain relief and MIO improvement, Gonzá- although a clear improvement in pain and mandib- 1112
1056 lez-Garcı́a and Rodrı́guez-Campo,44 in a series of ular function was noted. In a series of 30 patients 1113
1057 156 patients undergoing ALL for the treatment of who underwent 2 consecutive ALL, Hamada and 1114

OMC699_proof ■ 20 October 2014 ■ 3:08 pm

 Minimally Invasive Temporomandibular Joint Surgery 11

1115 colleagues47 concluded that a clinically verified an increasing success rate for both ALL and OA, 1172
1116 improvement in patients with ID of the TMJ was at each point during follow-up, from the first month 1173
1117 not necessarily accompanied by healing of the to the second year postoperatively. This improve- 1174
1118 diseased tissues. According to the study by ment was also comparable with the increase of 1175
1119 Moses and Topper48 of the position of the disk af- mouth opening, for both arthroscopic techniques 1176
1120 ter ALL assessed by MRI, the effect of lysis and (Table 4). 1177
1121 lavage is not related to the reposition of the disk There is controversy with regards to the posi- 1178
1122 in long-term follow-up but to the mobilization of tion of the disk in relation to the appearance of 1179
1123 the disk and the removal of degenerative products symptoms in the TMJ. Some investigators have 1180
1124 that produce inflammation. advocated for anatomic reduction of the disk 1181
1125 by open surgery or by OA to control the disease, 1182
1126 whereas others have reported excellent results 1183
Operative or Advanced Arthroscopy
1127 with arthrocentesis or ALL. Up to 34% of asymp- 1184
1128 Preliminary good results with OA were obtained tomatic volunteers have been reported to pre- 1185
1129 by McCain and de la Rua,26 Davis and col- sent with disk displacement, whereas a normal 1186
1130 leagues,49 and Tarro,50 although direct compari- position of the disk has been observed in 16% 1187
1131 son studies between OA and ALL were still to 23% of symptomatic patients. In a recent 1188
1132 absent. In a posterior study by Indresano,31 study by our group (unpublished results) of 1189
1133 103 of 188 patients who underwent ALL, and more than 36 TMJ asymptomatic volunteers, ID 1190
1134 121 of 212 patients who underwent OA, were caused by disk malposition was reported by 1191
1135 evaluated and compared in relation to pain and NMR imaging in 25% of the joints and 30.5% 1192
1136 function. Within the group of patients with ALL, of the individuals; disk displacement with reduc- 1193
1137 followed for 8.3 years, pain was reduced by tion was corrected in 13.8%, disk displacement Q9 1194
1138 71%, and disability was reduced by 66%. In without reduction in 9.7%, and anchored disk 1195
1139 comparison, patients undergoing OA, with a phenomenon in 1.3% of the TMJs. The investiga- 1196
1140 mean follow-up of 4.8 years, showed a pain tors conclusions regarding this findings were: (1) 1197
1141 reduction of 81% and a disability improvement a high prevalence of disk displacement of up to 1198
1142 of 86%. In this study, differences were statisti- approximately 30% (25% of the joints) was 1199
1143 cally significant. In contrast, in a comparison observed in asymptomatic patients in our study 1200
1144 study of 41 joints treated with ALL and 73 joints population; (2) disk and condylar morphology 1201
1145 treated with OA in patients with advanced ID was altered in asymptomatic patients with disk 1202
1146 (Wilkes III–V), Miyamoto and colleagues51 found displacement, whereas the glenoid fossa 1203
1147 similar good results in pain and function for morphology was unaltered independently of the 1204
1148 both treatment modalities. disk position; (3) a reduced angle between the 1205
1149 Regarding the success rate according to the major condylar axis and the temporal fossa refer- 1206
1150 stage of ID, variable results have previously been ence plane was found to be predictive for disk 1207
1151 reported in the literature. Bronstein and Merrill24 displacement; and (4) the craniomandibular in- 1208
1152 observed a success rate of 96% for stage II, dex was 2.5 times higher in asymptomatic pa- 1209
1153 83% for stage III, 88% for stage IV, and 63% for tients with disk displacement than in those with 1210
1154 stage V. These investigators used ALL and also normally positioned disk, thus constituting a clin- 1211
1155 OA. Holmlund and colleagues38 reported a suc- ical tool for differential diagnosis in the daily 1212
1156 cess rate of only 50% for patients suffering CCL practice. 1213
1157 with osteoarthrosis, corresponding to Wilkes 1214
1158 stage V, whereas Murakami and colleagues52 re- COMPLICATIONS AND CONCERNS 1215
1159 ported a success rate of approximately 90% for 1216
1160 ALL in stages III and IV and needed OA for a suc- Although uncommon, some complications have 1217
1161 cess rate of 93% in stage V. Recently, in a study of been reported for MITMJS. Most complications 1218
1162 26 joints that underwent ALL, Smolka and col- appear during or immediately after the proce- 1219
1163 leagues43 found an overall acceptable success dure and most of them recover uneventfully. 1220
1164 rate of 78.3%, although the treatment was less González-Garcı́a and colleagues,53 in a series 1221
1165 successful for stages IV and V (71.4% and 75%, of 500 patients (670 joints) with TMJ ID from 1222
1166 respectively) than for stages II and III (80% and Wilkes II to V who underwent arthroscopy, re- 1223
1167 85.7%, respectively). In relation to decrease of ported an overall 1.34% complication rate. 1224
1168 pain lower than 20 in the VAS score (0–100) and Although not considered as a true complication, 1225
1169 the increase of mouth opening more than bleeding within the SJS was observed in 8.5% of 1226
1170 30 mm, according to the AAOMS criteria,45,46 the arthroscopies; it is essential to reduce 1227
1171 González-Garcı́a and Rodrı́guez-Campo44 found bleeding by means of adequate instrumentation 1228

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 1285
1284
1283
1282
1281
1280
1279
1278
1277
1276
1275
1274
1273
1272
1271
1270
1269
1268
1267
1266
1265
1264
1263
1262
1261
1260
1259
1258
1257
1256
1255
1254
1253
1252
1251
1250
1249
1248
1247
1246
1245
1244
1243
1242
1241
1240
1239
1238
1237
1236
1235
1234
1233
1232
1231
1230
1229

12
González-Garcı́a
Table 4
Evolution of pain and mouth opening and success rate from the preoperative time to the second year postoperatively for ALL and OA or advanced
arthroscopy through Wilkes stages II to V. Success rates through the follow-up are reported in terms of percentage (%) of patients who presented with a
VAS score less than 20 and MIO higher than 30, according to the AAOMS Q15

1 mo 3 mo 6 mo 12 mo 24 mo
OMC699_proof ■ 20 October 2014 ■ 3:08 pm

Number of Postoperative/ Postoperative/ Postoperative/ Postoperative/ Postoperative/

Wilkes Patients/ Arthroscopic VAS (0–100)/ Success Rate Success Rate Success Rate Success Rate Success Rate
Stage Joints Technique MIO Preoperative (%) (%) (%) (%) (%)
II 52/72 ALL VAS (%) 52 30/38 27/61 24/75 35/60 20/88
MIO (mm)/(%) 39/— 34/58 38/70 37/61 39/75 38/74
OA VAS (%) 57 29/43 21/65 18/91 35/74 30/78
MIO (mm)/(%) 38/— 32/40 36/66 42/91 40/71 43/91
III 132/183 ALL VAS (%) 55 26/56 25/71 26/71 26/75 23/86
MIO (mm)/(%) 36/— 32/33 35/68 38/73 38/79 39/78
OA VAS (%) 57 32/40 32/59 26/69 22/69 27/74
MIO (mm)/(%) 34/— 29/20 33/50 36/6 37/74 38/74
IV 252/333 ALL VAS (%) 53 33/46 28/57 25/71 22/73 17/87
MIO (mm)/(%) 25/— 30/21 32/35 35/52 35/61 38/66
OA VAS (%) 53 35/40 30/61 26/69 20/76 15/86
MIO (mm)/(%) 24/— 28/11 30/29 35/53 36/62 37/71
V 17/23 ALL VAS (%) 37 43/— 20/— 17/— —/— —/—
MIO (mm)/(%) 29/— 26/— 29/— 28/— —/— —/—
OA VAS (%) 61 47/— 32/— 13/— —/— —/—
MIO (mm)/(%) 25/— 28/— 27/— 30/— —/— —/—
Adapted from González-Garcı́a R, Rodrı́guez-Campo FJ. Arthroscopic lysis and lavage versus operative arthroscopy in the outcome of temporomandibular joint internal derange-
ment: a comparative study based on Wilkes stages. J Oral Maxillofac Surg 2011;69:2513–24; with permission.
1342
1341
1340
1339
1338
1337
1336
1335
1334
1333
1332
1331
1330
1329
1328
1327
1326
1325
1324
1323
1322
1321
1320
1319
1318
1317
1316
1315
1314
1313
1312
1311
1310
1309
1308
1307
1306
1305
1304
1303
1302
1301
1300
1299
1298
1297
1296
1295
1294
1293
1292
1291
1290
1289
1288
1287
1286
 Minimally Invasive Temporomandibular Joint Surgery 13

1343 and by paying attention to essential points of the FUTURE TRENDS FOR MINIMALLY INVASIVE 1400
1344 surgical technique. Although no definitive paraly- TEMPOROMANDIBULAR JOINT SURGERY 1401
1345 sis of the facial nerve was observed, temporal Summary 1402
1346 paresis of the facial nerve was observed in 1403
Computer-assisted arthroscopy
1347 0.6% of the series. 1404
1348 Some of the observed complications are  Computer-assisted arthroscopy has been re- 1405
1349 included in the following list27: ported as one of the most promising tech- 1406
1350 niques for MITMJS.54 As an application of 1407
1351  Hemarthrosis, as a consequence of damage 1408
what has already been performed in endo-
1352 of the superficial temporary artery or vein dur- 1409
scopic sinus surgery or abdominal endos-
1353 ing entrance of the trocar at the fossa punc- 1410
copy, guiding the movements of the
1354 ture site, or as a consequence of damage of 1411
arthroscope or the instruments used in trian-
1355 the pterigoid artery during the anterior release 1412
gulation and OA may be helpful in difficult
1356 of the disk by miotomy 1413
TMJ cases, such as patients with obesity, tu-
1357  Infection of the skin area or infectious arthritis 1414
mors, ankylosis, or ID with fibrosis and a
1358 (infrequent with adequate sterilization of the 1415
severely limited upper joint space.
1359 surgical field and instrumentation) 1416
 With the preliminary idea of showing recalcu-
1360  Damage to the seventh cranial nerve and 1417
lated MRI or computed tomography (CT)
1361 facial palsy by involvement of the frontotem- 1418
scan sections, Wagner and colleagues54
1362 poral or the zygomatic branch 1419
developed a system that could visualize both
1363  Damage of the auriculotemporal nerve, which 1420
video and CT scans or MRI independently
1364 crosses posterior to the fossa puncture site 1421
on 2 or more channels, and also to superim-
1365 (anesthesia of the zone) 1422
pose projected anatomic structures on any
1366  Damage of the eighth cranial nerve, tympanic 1423
online video obtained by the arthroscope.
1367 disruption, and ossicle disruption with entry in 1424
 Although radiography is not performed intrao-
1368 the middle ear, otitis media, and hypoacusia 1425
peratively, changes in soft tissues such as
1369 (Fig. 15) 1426
those caused by synovitis or changes in disk
1370  Damage of the maxillary artery and its collat- 1427
position (ie, disk retroposition after anterior
1371 erals with/without arteriovenous fistula, as it 1428
release) may not be detected by CT scans or
1372 crosses laterally to the lateral pterigoid mus- 1429
MRI. Thus, only bony structures in relation to
1373 cle (uncommon) 1430
the TMJ act as a reference.
1374  Damage of the superficial temporal vessels, 1431
 Although primary goals of this technology are
1375 as they cross posterior to the puncture site; 1432
decreasing complication rate and operating
1376 external compression is needed 1433
time, educational, scientific, and training
1377  Perforation of the glenoid fossa with entrance 1434
goals may also be relevant.
1378 into the middle cranial fossa and subsequent 1435
1379 cerebrospinal fluid leak: if the leak persists 1436
for more than 48 hours, a lumbar drain has Navigation and arthroscopy
1380 1437
1381 to be placed by the neurosurgeon  Acquired images of the TMJ (preferably MRI) 1438
1382 can be loaded into an intraoperative naviga- 1439
1383 tion system to guide joint space manipulation. 1440
1384 The navigation system consists of a com- 1441
1385 puter, a monitor, a detector, and a series of 1442
1386 emitters or trackers.55 1443
1387  Among its applications: (1) injection and 1444
1388 sampling of intra-articular tissue and fluid; 1445
1389 (2) other intra-articular more mechanical 1446
1390 maniupulations56 (triangulation and entrance 1447
1391 of the working cannula in the upper joint 1448
print & web 4C=FPO

1392 compartment). 1449

1393  Advantages: (1) decrease of error in access: 1450
1394 either by the arthroscope or by the working 1451
1395 cannula in the process of triangulation; (2) 1452
1396 decrease of the risk of damaging intra- 1453
1397 articular tissue and structures by instrumenta- 1454
1398 Fig. 15. Complication during the arthroscopic proce- tion; (3) more accuracy in detecting and 1455
1399 dure: perforation of the middle ear. treating intra-articular disease. 1456

OMC699_proof ■ 20 October 2014 ■ 3:08 pm

 14 González-Garcı́a

1457 Improvement in cameras and optical lens 8. Israel HA. Technique for placement of a discal trac- 1514
1458 tion suture during temporomandibular joint arthros- 1515
1459  Improvements in camera and optical lens copy. J Oral Maxillofac Surg 1989;47:311–3. 1516
1460 technology will lead to better diagnosis of 9. Tarro AW. Arthroscopic treatment of anterior disc 1517
1461 subjacent tissue damage. Designing smaller displacement: a preliminary report. J Oral Maxillofac 1518
1462 and more flexible scopes will allow the sur- Surg 1989;47:353–8. 1519
1463 geon to perform the procedure in a less inva- 10. Ohnishi M. Arthroscopic surgery for hypermobility 1520
1464 sive manner or even under local anesthesia in and recurrent mandibular dislocation. Oral Maxillo- 1521
1465 an office-based setting.56 fac Surg Clin North Am 1989;1:153–64. 1522
1466 Design of nonhuman synthetic models for 11. McCain JP, Podrasky AE, Zabiegalski NA. Arthro- 1523
1467 training in minimally invasive scopic disc repositioning and suturing: a preliminary 1524
1468 temporomandibular joint surgery report. J Oral Maxillofac Surg 1992;50:568–79. 1525
1469 12. Tarro AW. A fully visualized arthroscopic disc suturing 1526
1470  Although access to hands-on cadaver technique. J Oral Maxillofac Surg 1994;52:362–9. 1527
1471 courses is scarce and expensive, the devel- 13. Goizueta Adame CC, Muñoz-Guerra MF. The poste- 1528
1472 opment of synthetic models of the TMJ may rior double pass suture in repositioning of the 1529
1473 play a role in the development of educa- temporomandibular disc during arthroscopic sur- 1530
1474 tional and training programs for MITMJS. gery: a report of 16 cases. J Craniomaxillofac Surg 1531
1475 These models must accurately reproduce 2012;40:86–91. 1532
1476 the anatomy of the joint and must also simu- 14. Yang C, Cai XY, Chen MJ, et al. New arthroscopic 1533
1477 late the surgeon’s proprioception for intro- disc repositioning and suturing technique for treat- 1534
1478 duction of the arthroscope and additional ing an anteriorly displaced disc of the temporoman- 1535
1479 instrumentation through the triangulation dibular joint: part I–technique introduction. Int J Oral 1536
1480 process. Maxillofac Surg 2012;41:1058–63. 1537
1481  Virtual models of arthroscopic procedures 15. Murakami K, Iizuka T, Matsuki M, et al. Recapturing the 1538
1482 reproducing normal and pathologic condi- persistent anteriorly displaced disk by mandibular 1539
1483 tions may be added to the synthetic models manipulation after pumping and hydraulic pressure 1540
1484 of the TMJ, so that the surgeon in training to the upper joint cavity of the temporomandibular 1541
1485 may visualize on the monitor the arthroscopic joint. Cranio 1987;5:17–24. 1542
1486 anatomy of normal or affected joints as they 16. Nitzan DW, Dolwick MF, Martinez GA. Temporoman- 1543
1487 practice the movements of the scope and dibular joint arthrocentesis: a simplified treatment for 1544
1488 instrumentation through the working severe, limited mouth opening. J Oral Maxillofac 1545
1489 cannula. Surg 1991;49:1163–7. 1546
1490 17. González-Garcı́a R, Gil-Dı́ez Usandizaga JL, Rodrı́- 1547
1491 REFERENCES guez-Campo FJ. Arthroscopic anatomy and lysis 1548
1492 and lavage of the temporomandibular joint. Atlas 1549
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RAÚL GONZALEZ-GARC IA, MD, PhD, FEBOMFS, Consultant Surgeon, Department of Oral and
Maxillofacial-Head and Neck Surgery, University Hospital Infanta Cristina; International Member of the
American Society of Temporomandibular Surgeons (ASTMJS), Active Member of the European Society of
Temporomandibular Surgeons (ESTMJS), Honorary Professor, University of Extremadura (UEx) School
of Medicine, Badajoz, Spain
Q3 Two different synopses were given in the manuscript, hence one has been retained, but edited down to less
than 100 words. Please confirm OK, or submit a replacement (also less than 100 words). Please note that the
synopsis will appear in PubMed: Several open surgeries have been proposed for the treatment of internal
derangement (ID) of the temporomandibular joint (TMJ), although minimally invasive temporomandibular
joint surgery (MITMJS) plays a major role in the treatment of ID and has been widely used for the treatment
of ID of the TMJ. Arthrocentesis, arthroscopic lysis and lavage, and operative or advanced arthroscopy are
the 3 most relevant techniques for MITMJS; clear indications for their application and a detailed
description of each technique are presented. Also, clinical outcomes for each technique from the most
relevant studies in the literature are reported.
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 Q7 Originally Refs. 20e22 were not cited in the text. Hence they have been combined with the citation of
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